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Family Doctor Services and I.T.

This speech was given in the House of Commons on 11 November 2004
Mr. Richard Bacon (South Norfolk) (Con): I am pleased to have the chance to speak in this debate. The motion calls on the Government

"to ensure that the NHS Programme for information technology delivers the choice of suppliers and functionality which general practitioners need".

I wish to focus specifically on that issue. The IT programme in the NHS is undoubtedly of huge importance, but GPs have serious concerns about it, not least because they are, at the moment, the controllers of information about patients. Eventually, under the proposals, it is likely that most information will be held centrally and a wider range of people will have access to it.

Worryingly, many of the characteristics of the most famous IT fiascos in the public sector - there are examples almost everywhere one looks - are exhibited by the national programme. The first is what the elder George Bush called "the vision thing". While for most undertakings some sense of where one is going is necessary, a grand vision for IT projects can be the most dangerous thing to have. Tony Collins, the specialist computer journalist, writes in his book "Crash: Ten Easy Ways to Avoid a Computer Disaster":

"In computer disaster terms a vision is an essential first step".

All the evidence and reports that the Public Accounts Committee sees suggest that failed IT projects have in common the failure to take things step by step, the failure to build on what is already known, the failure to be incremental and infection by the vision thing. The national programme exhibits the vision thing in huge measure. It will cost 6.2 billion with an unknown amount on top for implementation.

The second problem is lack of consultation. In the Criminal Records Bureau fiasco, there was a huge lack of consultation. An August issue of Computer Weekly contained a survey by Medix that found that

"Doctors feel left out of NHS IT plans".

In answer to a question about how much information they had had about the IT project, 3 per cent. said that they had had a lot of information, 26 per cent. had had some information, but 31 per cent. had had not much information, 29 per cent. had had no information but had heard of it, and a further 11 per cent. said that it was the first they had heard of it. In other words, 71 per cent. of those responding had had little or no information. In answer to a question about what consultation they had experienced personally about the IT project, 10 per cent. said that it had been barely adequate, 15 per cent. said it had been inadequate and 70 per cent. said that they had experienced none - a total of 95 per cent. of the respondents.

The third characteristic of IT disasters, which will be worryingly familiar to students of such matters, is a high turnover of staff involved. Sir John Pattison, one of the original architects and the first senior responsible owner of the programme, has gone. Lord Hunt, who was the Minister in charge, has gone. Richard Granger, the director general of IT in the health service, slums along on a salary of 200,000 and is the highest paid civil servant in the UK, but he earns a lot less than he would in the private sector. I attended a conference recently that had promotion stands for local service providers and I mentioned to one of them that I had heard that Richard Granger would be moving on soon and they said that they had heard that too. We shall watch eagerly to see how long Mr. Granger remains in his job now that the LSP contracts have been let. Of course, he was never responsible for clinical buy-in to the programme; it was explicit that he had no responsibility for getting clinicians involved. The Department of Health suddenly noticed that that was a bit of a problem, so rather late in the day - in March 2004, two years after the announcement of the programme - it appointed Dr. Aidan Halligan, the deputy chief medical officer, as the joint senior responsible owner of the programme. Yet six months later, in September, we found that Dr. Halligan was to return to his native country to take up a post as the head of the health service in Ireland, having achieved more or less nothing in terms of clinical buy-in during his six months in the job.

The fourth characteristic is indeed buy-in and most projects that do not work fail in that respect. That is where the alarm bells really start to ring. What must be, even for students of IT disasters, the locus classicus of such disasters was the Wessex regional health authority, where there was a Department of Health project for a central system that had to be imposed regionally, and a key issue was the failure to achieve clinical buy-in. It simply did not happen, so the district health authorities refused to fund the project and the Department had not choice but to cancel it. The fear is that primary care trusts will be put in a similar position and will not have sufficient funding to make the programme work, especially when their clinicians do not want it, do not like it and do not trust it anyway.

Clinical buy-in is incredibly important, because clinicians need to understand who has put the data into the system. They are unlikely to trust data unless they know how it was acquired and whether it is reliable. There is also a huge question about who will have access to such data. Are the proposed controls on access and the security protocols adequate to the task? Do they meet the concerns of GPs and patients about maintaining the privacy of what is often sensitive information? There is implied consent in data going up to the national spine in the programme; even if patients do not give consent, the data will be wrapped so that it is not easily readable. I was told today that consultants can look at any data, including that of patients who are not their own, and change the consent tag without obtaining the patient's permission. There are serious concerns about access to data, as well as about clinical buy-in generally.

The fifth characteristic often found in failed IT projects relates to funding. The Minister of State, who, sadly, is not in the Chamber at the moment, did what can only be described as a magnificent job in adding to the confusion in an interview on Radio 4 a couple of weeks ago, which was lovingly and forensically reproduced in Computer Weekly under the headline, "Health Minister adds to uncertainty over implementation costs of the NHS IT plan". It included a photograph of the Minister in which he is gesturing. I think that he is trying to explain something but unfortunately his expression makes him look like a white rabbit caught in a headlight, so whether he is on the receiving end of something or trying to give an explanation is not clear. What is certain, however, is that he did not make things easier to understand when he said:

"We think it is going to cost the same".

In other words, the 1 billion currently being spent on IT in the health service will cover all the changes required, taking no account of the fact that there is a series of IT issues in the health service, such as finance, payroll, manpower, staff rostering and the procurement of food and clinical and other services, as well as specialist equipment for immunisation programmes, none of which has anything to do with the national programme for IT.

The hon. Member for Sutton and Cheam (Mr. Burstow) received a little more clarity when pursuing a question put by my hon. Friend the Member for Westbury (Dr. Murrison). The Minister said:

"Future funding to the NHS determined by the SR2004 expenditure settlement will enable trusts to achieve the target of 4 per cent. for total NHS spending on IT, set by the 2002 Wanless Report."[Official Report, 4 November 2004; Vol. 426, c. 393W.]

Four per cent. is much higher than the current figure so that is not consistent with the statement, "We think it is going to cost the same". Any light that the Minister of State can shed in the wind-up will be most welcome.

To summarise, we have a massive vision, even though we know that in IT the vision thing is one of the most dangerous elements; indeed, it is a key ingredient of any computer disaster. We have lack of consultation on a spectacular scale. We have a high rate of staff turnover, although it has not yet reached the rate achieved during the implementation of the national probation service information systems strategy, which had seven programme managers in seven years, five of whom knew nothing about project management. One fears that we may be reaching that point. We also have a lack of buy-in - always a key worry, and in this case buy-in by clinicians, the people who matter the most - and we have huge questions about funding. This is a hardly a recipe for certainty or confidence and it is hardly surprising that GP magazine has said of the national programme for IT in the health service that it is likely to be more of a fiasco than the dome.

All of this is before one takes into account the effects of the new GP contract, and the way that it interlocks and dovetails, or, rather, does not interlock and dovetail, with the local service provider contracts that Mr. Granger has been so busy letting at such a high speed. As my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) mentioned, the GMS contract says in paragraph 4.34:

"Each practice will have guaranteed choice from a number of accredited systems",

but the local service provider contracts, which are roughly 1 billion apiece across the country, say more or less the opposite; that LSPs can impose a main system on local commissions with one alternative.

This brings us back to a point that was made earlier about the EMIS system, which is currently used by 55 per cent. of general practitioners, which is not involved in any of the local service provider contracts, unfortunately; mainly because the company could not get professional indemnity insurance because of the risks that insurers thought that it, as a relatively small company compared with the very large contractors who are LSP contractors, would have to take on. So we have the ludicrous situation in which GPs are in some cases having to turn away from a system that works, the EMIS system, and turn towards a system that in some cases has not even been written yet.

Until recently I was not familiar with the phrase "vapourware", but I am told that it means a system that exists, so far, only in someone's head; it has not even reached the back-of-the-envelope stage. No one who knows anything about EMIS or Vision or any of the other systems would say that they are perfect, but at least they were incrementally developed. They were not infected by the vision thing, they responded to what local clinicians wanted, they have continued to change in response to the needs of GPs in helping their patients, and GPs like the systems and want to carry on using them.

The Department reckons that, given the choice between getting something for free and having to pay for a system like EMIS, GPs will choose to go for something that is free. The Department is probably right that some of them will, but I think that it will be surprised, and I predict that many GPs will choose a system that they know, trust and understand, even if they have to pay for it. The point is that they should not have to pay for it; there should be no discrimination in funding between systems that GPs can rely on and ones that are still in the ether.

The areas that I would like to see the Minister focus on in the wind-up are as follows. First, specifically in relation to EMIS, will the Minister give a guarantee that there will not be an imbalance in the funding between systems such as EMIS and systems provided by the national programme for IT? Will Ministers listen to GPs' ongoing concerns about the potentially huge problems of data transfer? The other day I received a letter about that from a GP in Suffolk; the problems are potentially enormous. Can the Minister say whether the national programme understands better the benefits of the project rather than the risks, because where things go wrong it is nearly always the case that people have underestimated the risks?

Should 6 billion of contracts have been signed before it was known what the overall costs would be, including the costs of local implementation, before it was known what changes in business processes would be necessary, before it was known whether clinicians would use systems that were sought to be imposed centrally, before it was known how the benefits would be measured, before it was known whether GPs would oppose any handover of control of the confidentiality of their patient records and before it was known whether there were enough in-house skills to translate national plans into local action?

Finally, the National Audit Office, interestingly, has already announced an investigation into the national programme, which may shed light on some of these questions. But in the meantime I look to the Minister for an assurance that GPs will not be forced to replace trusted, well developed, well understood systems that provide what they want and enable them to help patients, with distrusted, less well developed, less well understood systems that may end up costing taxpayers a fortune without delivering what is required.


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